Rituximab is highly effective in children and adolescents with Burkitt lymphoma in Risk Groups R2 to R4

Prognostic Value of Peripheral Blood Lymphocyte Subsets in Children and Adolescents with High-Grade Mature B-Cell Non-Hodgkin Lymphoma: A Real-World Outcomes Study

BACKGROUND

Little progress has been made in determining prognostic factors for patients with high-grade mature B-cell non-Hodgkin lymphoma (HG B-NHL). Based on the important role of lymphocytes in cancer progression, this study aimed to explore the effect of peripheral blood lymphocytes on the prognosis of pediatric HG B-NHL.

METHODS

Patients aged less than 18 years with newly diagnosed HG B-NHL were enrolled. Peripheral blood lymphocyte subset levels were detected at diagnosis, and their optimal cutoff values were determined according to event-free survival (EFS).

RESULTS

In total, 206 patients were enrolled. The 5-year EFS and overall survival (OS) rates of the whole group were 92.1% ± 1.9% and 96.6% ± 1.3%, respectively. The 5-year EFS rate was worse in patients with a low relative CD4+ T-cell count (87.2% vs. 97.0%, p = 0.008), high relative CD8+ T-cell count (79.1% vs. 93.4%, p = 0.03), low CD4/CD8 ratio (80.5% vs. 94.2%, p = 0.01), and low B-cell count (80.0% vs. 93.4%, p = 0.02) at diagnosis than their counterparts. Cox multivariate analysis identified low relative CD4+ T-cell (HR = 4.91) and B-cell (HR = 3.87) counts at diagnosis as independent adverse prognostic factors. Patients with simultaneously low levels of CD4+ T and B cells had the worst outcomes in the entire cohort, with a 5-year EFS rate of 60.0%.

CONCLUSION

Low relative CD4+ T-cell and B-cell counts at diagnosis are associated with poor prognosis in children and adolescents with HG B-NHL in the real world.

Use of rituximab in mature, high-grade and advanced-stage pediatric B-lineage non-Hodgkin lymphomas: a systematic review, meta-analysis and the Brazilian reality

Objectives

Rituximab is a valuable agent for treating adult B-cell non-Hodgkin lymphoma (B-NHL), and several studies have tested its efficacy in children with mature, high-grade B-NHL. The aim of the present study was to systematically review the use of rituximab in children and adolescents with high-grade mature B-NHL and to conduct a meta-analysis of the evidence. Since access to this medication in public health systems in low- and middle-income countries is complex, we were also interested in mapping access to it in Brazil.

Methods

We conducted a systematic review and meta-analysis on the survival of pediatric patients with mature, high-grade and advanced-stage B-NHL treated with rituximab in combination with chemotherapy in first-line treatment or later. Patients' access to the medication was evaluated through a questionnaire sent to oncologists in Brazilian pediatric oncology centers.

Results

We selected 17 trials, which were subsequently grouped by disease type and line of therapy. In patients receiving first-line treatment, excluding those with primary mediastinal B-cell lymphoma (PMBL), the use of rituximab resulted in (1) better event-free survival [Hazard Ratio of 0.37 (0.22, 0.61); p < 0.01]; (2) a reduced risk of events [odds ratio of 0.44 (0.26-0.76); p = 0.003]; and (3) a reduced risk of death [odds ratio of 0.44 (0.21-0.89); p = 0.02]. In refractory or relapsed (R/R) patients, rituximab use was associated with a decreased chance of death [odds ratio of 0.25 (0.09-0.75); p = 0.01]. Additionally, our survey included 31 Brazilian centers, 63% of which reported bearing the cost of rituximab.

Conclusion

Rituximab improves outcomes in pediatric patients receiving first-line treatment for high-grade B-NHL (except PBML) and overall survival in R/R patients. However, access to rituximab in Brazilian hospitals is currently dependent on centers supporting its economic burden.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, PROSPERO (CRD42021292912).

Effects of different doses of rituximab on immunoglobulin levels in high-risk pediatrics with Burkitt's lymphoma

Studies have confirmed that rituximab (RTX) can improve the efficacy of BL, but there is a certain effect on the level of immunoglobulin, which will lead to the verification of infection, and the previous study of our center has confirmed that reducing the dose of RTX (4 doses) can achieve a similar effect to the standard dose of RTX (6 doses), can it reduce the effect on the level of immunoglobulin? To date, few studies have concentrated on the effects of immunoglobulin (Ig) on Chinese paediatric patients. This study aimed to examine whether there is a variation in the impact of different doses of RTX on immunoglobulin levels in the high-risk group of children with BL. Clinical data of high-risk pediatric patients with BL who were treated in Beijing Children's Hospital (Beijing, China) were retrospectively analysed. Baseline characteristics and serum Ig levels were collected at four distinct time points (t0 = pre-chemotherapy, t1 = at the end of chemotherapy, t2 = 6 months post-chemotherapy, t3 = 12 months post-chemotherapy). Ig levels were measured at various time points before and after treatment within three RTX treatment groups: R0 group (standard chemotherapy without RTX), R6 group (6 doses of RTX + chemotherapy), and R4 group (4 doses of RTX + chemotherapy). The objective was to compare whether differences existed among the three groups. The results revealed that the study enrolled 300 high-risk BL patients, including 256 boys and 44 girls, distributed across three groups based on RTX dosage: R0 group (n = 38), R6 group (n = 87), and R4 group (n = 175). Median Ig levels were assessed at four time points (t0, t1, t2, t3) for each group. In the R0 group, IgA and IgM levels significantly decreased at t1 compared with t0 (P = 0.006 and 0.002, respectively), while were gradually recovered at t2, returning to t0 levels at t3 (P = 0.073 and 0.293, respectively). IgG levels exhibited no significant difference between t0 and t1 (P = 0.89), reaching their lowest levels at t2 and returning to t0 levels at t3 (P = 0.14). In the R4 group, the minimum levels of IgA, IgM, and IgG were identified at t1 (P < 0.001, < 0.001, and < 0.001, respectively), which were gradually recovered at t2, while remained lower than t0 levels at t3 (P < 0.001, < 0.001, and = 0.005, respectively). The R6 group exhibited reduction in IgA and IgM levels at t1, with gradual recovery at t2 and t3, while remained lower than t0 levels (P = 0.003 and < 0.001, respectively). IgG levels in the R6 group decreased at t1 (P < 0.001) and did not return to t0 levels at t3 (P = 0.004). In the R4 and R6 groups, it was observed that children with hypogammaglobulinemia pre-RTX were more likely to combine with persistent hypogammaglobulinemia (PH-Ig) post-RTX. A 1:1 matched comparison between R4 and R6 groups (78 patients each) revealed consistently higher IgA, IgM, and IgG levels in the R4 group at each time point after chemotherapy. Notably, IgA and IgG levels recovered earlier in the R4 group than those in the R6 group (P < 0.05). Burkitt lymphoma in the high-risk group were more likely to complicated hypoimmunoglobulinemia after treatment, it is important to monitor Ig levels before and during treatment, and to inform replacement therapy for Ig. Compared with standard chemotherapy group, the RTX group had a longer time of low Ig and a slower recovery, reducing the dosage of rituximab can improve the recovery of IgA and IgG levels.

[Efficacy and safety of rituximab in children and adolescents with mature B-cell non-Hodgkin's lymphoma: a Meta analysis]

OBJECTIVES

To study the efficacy and safety of rituximab combined with chemotherapy in the treatment of children and adolescents with mature B-cell non-Hodgkin's lymphoma (B-NHL) through a Meta analysis.

METHODS

The databases including PubMed, Embase, the Cochrane Library, ClinicalTrials.gov, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and Weipu were searched to obtain 10 articles on rituximab in the treatment of mature B-NHL in children and adolescents published up to June 2022, with 886 children in total. With 3-year event-free survival (EFS) rate, 3-year overall survival (OS) rate, complete remission rate, mortality rate, and incidence rate of adverse reactions as outcome measures, RevMan 5.4 software was used for Meta analysis, subgroup analysis, sensitivity analysis, and publication bias analysis.

RESULTS

The rituximab+chemotherapy group showed significant increases in the 3-year EFS rate (HR=0.38, 95%CI: 0.25-0.59, P<0.001), 3-year OS rate (HR=0.29, 95%CI: 0.14-0.61, P=0.001), and complete remission rate (OR=3.72, 95%CI: 1.89-7.33, P<0.001) as well as a significant reduction in the mortality rate (OR=0.31, 95%CI: 0.17-0.57, P<0.001), as compared with the chemotherapy group without rituximab. There was no significant difference in the incidence rate of adverse reactions between the two groups (OR=1.28, 95%CI: 0.85-1.92, P=0.24).

CONCLUSIONS

The addition of rituximab to the treatment regimen for children and adolescents with mature B-cell non-Hodgkin's lymphoma can bring significant survival benefits without increasing the incidence of adverse reactions.

Infectious Complications of Targeted Therapies in Children with Leukemias and Lymphomas

Simple Summary

Targeted therapies in children with hematological malignancies moderate the effects of cytotoxic therapy, thus improving survival rates. They have emerged over the last decade and are used in combination with or after the failure of conventional chemotherapy and as bridging therapy prior to hematopoietic stem cell transplantation (HSCT). Nowadays, there is a growing interest in their efficacy and safety in pediatric patients with refractory or relapsed disease. The compromised immune system, even prior to therapy, requires prompt monitoring and treatment. In children with hematological malignancies, targeted therapies are associated with a comparable incidence of infectious complications to adults. The exact impact of these agents that have different mechanisms of action and are used after conventional chemotherapy or HSCT is difficult to ascertain. Clinicians should be cautious of severe infections after the use of targeted therapies, especially when used in combination with chemotherapy.

Abstract

The aim of this review is to highlight mechanisms of immunosuppression for each agent, along with pooled analyses of infectious complications from the available medical literature. Rituximab confers no increase in grade ≥3 infectious risks, except in the case of patients with advanced-stage non-Hodgkin lymphoma. Gemtuzumab ozogamicin links with high rates of grade ≥3 infections which, however, are comparable with historical cohorts. Pembrolizumab exhibits a favorable safety profile in terms of severe infections. Despite high rates of hypogammaglobulinemia (HGG) with blinatumomab, low-grade ≥3 infection rates were observed, especially in the post-reinduction therapy of relapsed B-acute lymphoblastic leukemia. Imatinib and nilotinib are generally devoid of severe infectious complications, but dasatinib may slightly increase the risk of opportunistic infections. Data on crizotinib and pan-Trk inhibitors entrectinib and larotrectinib are limited. CAR T-cell therapy with tisagenlecleucel is associated with grade ≥3 infections in children and is linked with HGG and the emergence of immune-related adverse events. Off-label therapies inotuzumab ozogamicin, brentuximab vedotin, and venetoclax demonstrate low rates of treatment-related grade ≥3 infections, while the addition of bortezomib to standard chemotherapy in T-cell malignancies seems to decrease the infection risk during induction. Prophylaxis, immune reconstitution, and vaccinations for each targeted agent are discussed, along with comparisons to adult studies.

[Clinical features and prognosis of children with Burkitt's lymphoma: an analysis of 62 cases]

OBJECTIVES

To study the clinical features and chemotherapy response of Burkitt's lymphoma (BL) in children and the influence of rituximab on the prognosis of children with BL.

METHODS

A retrospective analysis was performed for the medical data of 62 children with BL, including clinical features, therapeutic efficacy, and prognostic factors. The Cox regression model was used to identify the factors associated with poor prognosis in children with BL. According to whether rituximab was used, the children with advanced (stage III/IV) BL were divided into two groups: chemotherapy plus rituximab and chemotherapy alone. The prognosis was compared between the two groups.

RESULTS

For these 62 children, the median age of onset was 5 years (range 1-14 years), and there were 58 boys (94%) and 4 girls (6%). The primary site was abdominal cavity in 41 children (66%), and head and neck in 16 children (26%). There were 1 child with stage I BL (2%), 8 with stage II BL (13%), 33 with stage III BL (53%), and 20 with stage IV BL (32%). The median follow-up time was 29 months, with progression/recurrence observed in 15 children (24%), and the 3-year overall survival (OS) rate and event-free survival (EFS) rate were 82.8%±5.2% and 77.3%±5.8%, respectively. For the children with stage III/IV BL, there was a significant difference in the 3-year the OS rate between the chemotherapy plus rituximab group (16 children) and the chemotherapy alone group (30 children) (93.3%±6.4% vs 65.6%±9.9%, P=0.042), while there was no significant difference in the 3-year EFS rate between the two groups (86.2%±9.1% vs 61.8%±10.1%, P>0.05). The Cox regression analysis showed that central nervous system involvement, lactate dehydrogenase >1 000 U/L, and early incomplete remission were the factors associated with poor prognosis (P<0.05).

CONCLUSIONS

Chemotherapy combined with rituximab can improve the prognosis of children with stage III/IV BL. Central nervous system involvement, elevated lactate dehydrogenase level, and early incomplete remission may indicate a poor prognosis in children with BL.

Overall and event-free survival of childhood lymphoma in Greece: analysis of harmonized clinical data over a 24-year active registration period

We assessed event-free (EFS) and overall (OS) survival in 676 incident cases of childhood Hodgkin (HL) and non-Hodgkin (NHL) lymphoma actively registered in Greece (1996-2019). HL-OS_5-year was 96% and NHL-OS_5-year 85%, whereas HL-EFS_5-year was 86% and NHL-EFS_5-year was 81%, notably similar to the respective OS rates (HL: 95%, NHL: 85%) in developed countries. For HL, older age at diagnosis, high maternal education and close proximity to treatment centers were linked to remarkably favorable outcomes. By contrast, stage IV patients showed worse OS and EFS. HL patients with low levels of hemoglobin were associated with worse EFS (hazard ratio: 2.81, 95% confidence intervals: 1.09-7.22). OS (76%) and EFS (73%) were poor among high-risk NHL patients and those with increased LDH (71%). The identified predictors of poor disease outcome point to the need for intensification of individualized treatments. Ongoing clinical cancer registration entailing clinical components could contribute to use of state-of-the-art treatments.

The Clinical Accuracy and Risk Stratification in End of Therapy 18F-FDG PET/CT in Burkitt Lymphoma

Purpose

Burkitt lymphoma (BL) is an invasive lymphoma subtype with FDG avid at ¹⁸F-FDG PET/CT, but there is currently no validated criterion in treatment evaluation and prognosis prediction. The aim of this study was to analyze the clinical accuracy of ¹⁸F-FDG PET/CT in Burkitt lymphoma in end of therapy PET/CT (EOT-PET) to assess the treatment response in BL and conduct a survival analysis with different Deauville 5-point score (DS) cutoff values.

Materials and Methods

A total of 189 patients were retrospectively included: 97 underwent baseline PET/CT and all underwent EOT-PET. Survival curves were plotted according to the Kaplan-Meier method. Different DS cutoff values in EOT-PET were evaluated for risk stratification in Burkitt lymphoma.

Results

The median progression free survival (PFS) and overall survival (OS) were 52 and 53 months, respectively. Applying the conventional DS 4 to 5, there was significant difference in outcome between EOT-PET negative and positive patients. However, the positive predictive value (PPV) (28.3% for PFS and 26.4% for OS) is low despite a high negative predictive value (NPV) (94.1% for OS and 94.9% for OS). When we moved the cutoff point to DS 5, the PPV was improved evidently (88.2% for PFS and 82.3% for OS) with the satisfactory NPV simultaneously (95.3% for PFS and 95.9% for OS).

Conclusions

EOT-PET results using DS significantly related with PFS and OS. DS of 5 may be a better cutoff point at the end of treatment to determine whether patients have a significant risk of recurrence or progress.